Provider Demographics
NPI:1528597317
Name:LETENDRE, KRISTEN MARY (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARY
Last Name:LETENDRE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 STARLIGHT RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-4436
Mailing Address - Country:US
Mailing Address - Phone:718-442-7899
Mailing Address - Fax:
Practice Address - Street 1:1551 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-2313
Practice Address - Country:US
Practice Address - Phone:718-979-4350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-06
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007829-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant